MARYLAND INSURANCE ADMINISTRATION
JUNE 24, 2004
VIII. FORMS REVIEW
The examiners were provided a copy of each form used in the Agency. These forms included:
Replacement questionnaire form.
Notice regarding replacement form.
Armed Forces allotment certification form.
Direct deposit sign up form.
Federal employee premium payment agreement form.
Tax advisor form
Chase Manhattan bank allotment agreement form
Federal employee allotment form
The replacement notice form and the tax advisor form are required by Maryland regulations. These forms comply with COMAR 31.09.05.12. The application packages for insurance contain the following forms: Package 01065-5MD-Jan 1983 Application page 0106-5-A-MD Application page 0106-5-B-MD Application page 0106-5-AUTH-MD Application page 0106-5-N-MD Application page 0106-R-5-R-MD Package 036-18 MD (09/1999) Application page 036K-18 MD Application page 036K-18 MD (05/1998) Application page 036K-18 Receipt and Temporary Insurance Agreement page 036K-18-R MD The forms contained in the application packages were stamped and approved for use in Maryland.
MET LIFE REPORT NO. 786-01